Error-Prone Drug Name Abbreviations


The drug name abbreviations found in this table have been reported to the Institute for Safe Medical Practices (ISMP) through the ISMP Medication Error Reporting Program as being frequently misinterpreted and involved in harmful medication errors. These drug name abbreviations should never be used when communicating medical information; complete drug names should be used. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies.

Drug Name
Intended Meaning Misinterpretation Correction
Antiretroviral medications (eg, DOR, TAF, TDF) DOR: doravirine
TAF: tenofovir alafenamide
TDF: tenofovir disoproxil fumarate
DOR: Dovato (dolutegravir and lamiVUDine)
TAF: tenofovir disoproxil fumarate
TDF: tenofovir alafenamide
Use complete drug names
APAP acetaminophen Not recognized as acetaminophen Use complete drug name
ARA A vidarabine Mistaken as cytarabine (ARA C) Use complete drug name
AT II and AT III AT II: angiotensin II (Giapreza)
AT III: antithrombin III (Thrombate III)
AT II (angiotensin II) mistaken as AT III (antithrombin III) and vice versa Use complete drug names
AZT zidovudine (Retrovir) Mistaken as azithromycin, azaTHIOprine, or aztreonam Use complete drug name
CPZ Compazine (prochlorperazine) Mistaken as chlorproMAZINE Use complete drug name
DTO diluted tincture of opium, or deodorized tincture of opium (Paregoric) Mistaken as tincture of opium Use complete drug name
HCT hydrocortisone Mistaken as hydroCHLOROthiazide Use complete drug name
HCTZ hydroCHLOROthiazide Mistaken as hydrocortisone (seen as HCT250mg) Use complete drug name
MgSO4* magnesium sulfate Mistaken as morphine sulfate Use complete drug name
MS, MSO4* morphine sulfate Mistaken as magnesium sulfate Use complete drug name
MTX methotrexate Mistaken as mitoXANTRONE Use complete drug name
Na at the beginning of a drug name (eg, Na bicarbonate) Sodium bicarbonate Mistaken as no bicarbonate Use complete drug name
NoAC novel/new oral anticoagulant Mistaken as no anticoagulant Use complete drug name
OXY oxytocin Mistaken as oxyCODONE, OxyCONTIN Use complete drug name
PCA procainamide Mistaken as patient controlled analgesia Use complete drug name
PIT Pitocin (oxytocin) Mistaken as Pitressin (vasopressin) Use complete drug name
PNV prenatal vitamins Mistaken as penicillin VK Use complete drug name
PTU propylthiouracil Mistaken as Purinethol (mercaptopurine) Use complete drug name
T3 Tylenol with codeine No. 3 (acetaminophen with codeine) Mistaken as liothyronine Use complete drug name
TAC or tac triamcinolone or tacrolimus Mistaken as tetracaine, Adrenalin and cocaine; or as Taxotere, Adriamycin, and cyclophosphamide Use complete drug name. Avoid drug regimen or protocol acronyms that may have a dual meaning or may be confused with other common acronyms, even if defined in an order set.
TNK TNKase Mistaken as “TPA” Use complete drug name
TPA or tPA tissue plasminogen activator, Activase (alteplase) Mistaken as TNK (TNKase, tenecteplase), TXA (tranexamic acid), or less often as Retavase (retaplase) Use complete drug names
TXA tranexamic acid Mistaken as TPA (tissue plasminogen activator) Use complete drug name
ZnSO4 zinc sulfate Mistaken as morphine sulfate Use complete drug name
Drug Names
Intended Meaning Misinterpretation Correction
Coined names for compounded products (eg, magic mouthwash, banana bag) Specific ingredients compounded together Mistaken ingredients Use complete drug/product names for all ingredients
“Levo” levofloxacin Mistaken as Levophed (norepinephrine) Use complete drug name
“Neo” Neo-Synephrine (phenylephrine) Mistaken as neostigmine Use complete drug name
“Nitro” drip nitroglycerin infusion Mistaken as sodium nitroprusside infusion Use complete drug name
Number embedded in drug name (not part of the official name) (eg, 5-fluorouracil, 6-mercaptopurine) fluorouracil, mercaptopurine Embedded number mistaken as the dose or number of tablets/capsules to be given Use complete drug names, without an embedded number
“IV Vanc” intravenous vancomycin Mistaken as Invanz (ertapenem) Use complete drug name

*Included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. For more information visit


Source: Institute for Safe Medication Practices. List of Error-Prone Abbreviations. 2021.

Available at: Accessed August 29, 2022.

(Rev. 9/2022)